Healthcare Provider Details

I. General information

NPI: 1104449552
Provider Name (Legal Business Name): JACOB ROBERT AHLES DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2020
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 SOUTH DR
MOUNT PLEASANT MI
48858-3257
US

IV. Provider business mailing address

1221 SOUTH DR
MOUNT PLEASANT MI
48858-3257
US

V. Phone/Fax

Practice location:
  • Phone: 800-671-1453
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number5151014491
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: